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Introduction: Racial and ethnic minority groups have higher rates of SARS-CoV-2 infection, severe illness, and death; however, they receive monoclonal antibody (mAb) treatment at lower rates than non-Hispanic White patients. We report data from a systematic approach to improve equitable provision of COVID-19 neutralizing monoclonal antibody treatment. Methods: Treatment was administered at a community health urgent care clinic affiliated with a safety-net urban hospital. The approach included a stable treatment supply, a same-day test and treat model, a referral process, patient outreach, and financial support. We analyzed the race/ethnicity data descriptively and compared proportions using a chi-square test. Results: Over 17 months, 2524 patients received treatment. Compared to the demographics of county COVID-19-positive cases, a greater proportion of patients who received mAb treatment were Hispanic (44.7% treatment vs. 36.5% positive cases, p < 0.001), a lower proportion were White Non-Hispanic (40.7% treatment vs. 46.3% positive cases, p < 0.001), equal proportion were Black (8.2% treatment vs. 7.4% positive cases, P = 0.13), and equal proportion occurred for other race patients. Discussion: Implementation of multiple systematic strategies to administer COVID-19 monoclonal antibodies resulted in an equitable race/ethnic distribution of treatment.

Neutralizing monoclonal antibody treatments for non-hospitalized patients with COVID-19 have been available since November 2020. However, they have been underutilized and access has been inequitable. To understand, from the clinician perspective, the factors facilitating or hindering monoclonal antibody referrals, patient access, and equity to inform development of clinician-focused messages, materials, and processes for improving access to therapeutics for COVID-19 in Colorado. We interviewed 38 frontline clinicians with experience caring for patients with COVID-19 in outpatient settings. Clinicians were purposely sampled for diversity to understand perspectives across geography (i.e., urban versus rural), practice setting, specialty, and self-reported knowledge about monoclonal antibodies. Interviews were conducted between June and September 2021, lasted 21 to 62 minutes, and were audio recorded and transcribed verbatim. Interview transcripts were then analyzed using rapid qualitative analysis to identify thematic content and to compare themes across practice settings and other variables. Clinicians perceived monoclonal antibodies to be highly effective and were unconcerned about their emergency use status; hence, these factors were not perceived to hinder patient referrals. However, some barriers to access - including complex and changing logistics for referring, as well as the time and facilities needed for an infusion - inhibited widespread use. Clinicians in small, independent, and rural practices experienced unique challenges, such as lack of awareness of their patients' COVID-19 test results, disconnect from treatment distribution systems, and patients who faced long travel times to obtain treatment. Many clinicians held a persistent belief that monoclonal antibodies were in short supply; this belief hindered referrals, even when monoclonal antibody doses were not scarce. Across practice settings, the most important facilitator for access to monoclonal antibodies was linkage of COVID-19 testing and treatment within care delivery. Although clinicians viewed monoclonal antibodies as safe and effective treatments for COVID-19, individual- and system-level barriers inhibited referrals, particular in some practice settings. Subcutaneous or oral formulations may overcome certain barriers to access, but simplifying patient access by linking testing with delivery of treatments that reduce morbidity and mortality will be critical for the ongoing response to COVID-19 and in future pandemics.

Sotrovimab effectively prevented progression to severe disease and mortality following infection with pre-Omicron SARS-CoV-2 variants. We sought to determine whether sotrovimab is similarly effective against SARS-CoV-2 Omicron variant infection.Observational cohort study of non-hospitalized adult patients with SARS-CoV-2 infection from December 26, 2021 to March 10, 2022, using electronic health records from a statewide health system. We propensity matching patients not receiving authorized treatment for each patient treated with sotrovimab. The primary outcome was 28-day hospitalization; secondary outcomes included mortality. We also propensity matched sotrovimab-treated patients from the Omicron and Delta phases. Logistic regression was used to determine sotrovimab effectiveness during Omicron and between variant phases.Of 30,247 SARS-CoV-2 Omicron variant infected outpatients, we matched 1,542 receiving sotrovimab to 3,663 not receiving treatment. Sotrovimab treatment was not associated with reduced odds of 28-day hospitalization (2.5% versus 3.2%; adjusted OR 0.82, 95% CI 0.55, 1.19) or mortality (0.1% versus 0.2%; adjusted OR 0.62, 95% CI 0.07, 2.78). Between phases, the observed treatment odds ratio was higher during Omicron than during Delta (OR 0.85 vs. 0.39, respectively; interaction p=0.053).Real-world evidence demonstrated sotrovimab was not associated with reduced 28-day hospitalization or mortality among COVID-19 outpatients during the Omicron BA.1 phase.

Stakeholder engagement is increasingly expected by funders and valued by researchers in clinical and translational science, yet many researchers lack access to expert consultation or training in selecting appropriate stakeholder engagement methods. We describe the development of a novel Stakeholder Engagement Navigator webtool. We conducted an environmental scan and literature review, along with investigator interviews, surveys, and engagement expert facilitated group discussion. We formally reviewed and cataloged 29 distinct engagement methods. To develop the webtool, we used an iterative design process that followed Design Thinking phases: empathize, define, ideate, prototype, and test. As prioritized during user testing, the Stakeholder Engagement Navigator webtool both educates and guides investigators in selecting an engagement method based on key criteria. The V1.0 Navigator webtool filters methods first by purpose of engagement (noted by 62% of users as the highest priority criteria), then by budget, time per stakeholder interaction, and total interactions. The tool is available at DICEMethods.org. The Stakeholder Engagement Navigator webtool is a user-centered, interactive webtool suitable for use by researchers seeking guidance on appropriate stakeholder engagement methods for clinical and translational research projects.

Covid-19 Crisis Triage Crisis triage protocols should seek to optimize health outcomes, but doing so requires explicit protection of core values, such as the equal moral worth of all people, includ...

As we write, U.S. cities and states with extensive community transmission of Covid-19 are in harm's way-not only because of the disease itself but also because of prior and current failures to act. During the 2009 influenza pandemic, public health agencies and hospitals developed but never adequately implemented preparedness plans. Focused on efficiency in a competitive market, health systems had few incentives to maintain stockpiles of essential medical equipment. Just-in-time economic models resulted in storage of only those supplies needed then. At the same time, global purchasing in search of lower prices reduced the number of U.S. suppliers, with hospitals dependent on foreign companies. There is still a possibility that the pandemic will be manageably bad rather than unmanageably catastrophic in this country. Immediate, powerful, and sustained federal action could make the difference.

Background: The coronavirus disease 2019 pandemic has or threatens to overwhelm health care systems. Many institutions are developing ventilator triage policies. Objective: To characterize the development of ventilator triage policies and compare policy content. Design: Survey and mixed-methods content analysis. Setting: North American hospitals associated with members of the Association of Bioethics Program Directors. Participants: Program directors. Measurements: Characteristics of institutions and policies, including triage criteria and triage committee membership. Results: Sixty-seven program directors responded (response rate, 91.8%); 36 (53.7%) hospitals did not yet have a policy, and 7 (10.4%) hospitals' policies could not be shared. The 29 institutions providing policies were relatively evenly distributed among the 4 U.S. geographic regions (range, 5 to 9 policies per region). Among the 26 unique policies analyzed, 3 (11.3%) were produced by state health departments. The most frequently cited triage criteria were benefit (25 policies [96.2%]), need (14 [53.8%]), age (13 [50.0%]), conservation of resources (10 [38.5%]), and lottery (9 [34.6%]). Twenty-one (80.8%) policies use scoring systems, and 20 of these (95.2%) use a version of the Sequential Organ Failure Assessment score. Among the policies that specify the triage team's composition (23 [88.5%]), all require or recommend a physician member, 20 (87.0%) a nurse, 16 (69.6%) an ethicist, 8 (34.8%) a chaplain, and 8 (34.8%) a respiratory therapist. Thirteen (50.0% of all policies) require or recommend those making triage decisions not be involved in direct patient care, but only 2 (7.7%) require that their decisions be blinded to ethically irrelevant considerations. Limitation: The results may not be generalizable to institutions without academic bioethics programs. Conclusion: Over one half of respondents did not have ventilator triage policies. Policies have substantial heterogeneity, and many omit guidance on fair implementation., The coronavirus disease 2019 pandemic has overwhelmed health care systems or threatens to do so, and many institutions are developing ventilator triage policies. This study describes policies developed at hospitals associated with members of the Association of Bioethics Program Directors.

The term "professionalism" has been used in a variety of ways. In 2012, the American Board of Medical Specialties (ABMS) Standing Committee on Ethics and Professionalism undertook to develop an operational definition of professionalism that would speak to the variety of certification and maintenance-of-certification activities undertaken by ABMS and its 24 member boards. In the course of this work, the authors reviewed prior definitions of professions and professionalism and found them to be largely descriptive, or built around lists of proposed professional attributes, values, and behaviors. The authors argue that while making lists of desirable professional characteristics is necessary and useful for teaching and assessment, it is not, by itself, sufficient either to fully define professionalism or to capture its social functions. Thus, the authors sought to extend earlier work by articulating a definition that explains professionalism as the motivating force for an occupational group to come together and create, publicly profess, and develop reliable mechanisms to enforce shared promises-all with the purpose of ensuring that practitioners are worthy of patients' and the public's trust.Using this framework, the authors argue that medical professionalism is a normative belief system about how best to organize and deliver health care. Believing in professionalism means accepting the premise that health professionals must come together to continually define, debate, declare, distribute, and enforce the shared competency standards and ethical values that govern their work. The authors identify three key implications of this new definition for individual clinicians and their professional organizations.

Background Experts recommend that physician practices collect and use patient race, ethnicity, and primary language data to document and address health care disparities and improve health care quality for diverse populations. Little is known about demographic data collection in small practice settings. Objective To conduct an exploratory study to examine demographic data collection in physician practices to reduce disparities and provide qualitative descriptions of facilitators and barriers to data collection. Design Semistructured telephone interviews. Setting Medical practices with 5 or fewer physicians. Participants Practice managers, nurse managers, and physicians from 20 practices nationwide. Results Of the 20 practices interviewed, 9 reported collecting demographic data. Only 1 practice feature facilitated demographic data collection: use of an electronic medical record (EMR) system (7 of 10 practices with an EMR collected data). Participation in pay-for-performance programs, cultural competency training, and measuring clinical quality did not facilitate data collection. One practice linked demographic and quality data. A few used the data to track language service needs. The main perceived barriers to demographic data collection included concerns about privacy, the legality of collecting the information, possible resistance from patients and staff, difficulty recording the data, and uncertainty about whether the data would be useful. Conclusions Few small practices use data to track or address disparities in health care. Most perceived barriers to data collection can be surmounted. There is hope for improved collection and use of data through the spread of information technology with comprehensive national health reform.

Background In the United States, nearly half of undocumented immigrants with end-stage kidney disease receive hemodialysis only when they are evaluated in an emergency department and are found to have life-threatening renal failure ("emergency-only hemodialysis" [EOHD]). These patients experience psychosocial distress and much higher mortality than patients receiving regularly scheduled hemodialysis, but little is known about how providing EOHD affects the clinicians involved. Objective To understand clinicians' experiences providing EOHD. Design Qualitative study using semistructured interviews. Setting A safety-net hospital in Denver, Colorado, and a safety-net system in Houston, Texas. Participants Fifty interdisciplinary clinicians experienced in providing EOHD. Measurements Interviews were analyzed using thematic analysis. Outcomes included themes and subthemes. Results Four themes and 13 subthemes (in parentheses) were identified: 1) drivers of professional burnout (emotional exhaustion from witnessing needless suffering and high mortality, jeopardizing patient trust, detaching from patients, perceived lack of control over EOHD criteria, and physical exhaustion from overextending to bridge care), 2) moral distress from propagating injustice (altered care based on nonmedical factors, focus on volume at the expense of quality, and need to game the system), 3) confusing and perverse financial incentives (wasting resources, confusing financial incentives, and concerns about sustainability), and 4) inspiration toward advocacy (deriving inspiration from patients and strengthened altruism). Limitation Whether the findings apply to other settings is unknown, and social desirability response bias might have reduced reporting of negative perceptions and experiences. Conclusion Clinicians in safety-net settings who provide EOHD to undocumented patients describe experiencing moral distress and being driven toward professional burnout. The burden of EOHD on clinicians should inform discussions of systemic approaches to support provision of adequate care based on medical need. Primary funding source Robert Wood Johnson Foundation and Doris Duke Charitable Foundation.

Continuous quality improvement is a component of professionalism. Maintenance of Certification (MOC) is a mechanism in the USA for physicians to keep current with medical knowledge and contribute to practice improvement. Little is known about primary care physicians’ perceptions of the practice improvement (Part IV) components of MOC. We aimed to determine primary care physicians’ perceptions of their professional responsibility to participate in Part IV MOC. This was a cross-sectional study of primary care physicians using the American Medical Association Masterfile. We developed a nine-item survey, designed from expert consensus and literature to determine views on Part IV MOC as a professional responsibility. We surveyed 1500 randomly selected primary care physicians via mail from November 2014 to May 2015. The response rate was 42% (627 of 1,500): 47% (273 of 585) were family practitioners and 49% (289 of 585) were internists. Factor analysis revealed a two-factor survey, with five items pertaining to positive views of MOC Part IV and four items pertaining to negative views. Internists were more likely to view MOC Part IV as time consuming (82.0% vs. 70.3%, P = .001), expensive (50.9% vs. 38.8%, P = .004), and not relevant to practice (39.1% vs. 23.8%, P

The profession of medicine is based on a shared set of tacit and explicit agreements about what patients, doctors, and society at large should be able to expect from each other, a social contract that defines the profession. Historically, the development of this set of agreements depended upon the creation of social organizations that could speak for the entire profession. Over the last several decades, however, the perceived need for these organizations, and especially the umbrella organization for the profession, the American Medical Association, has waned. The reasons for this are complex, but the consequences are significant: an eroding social contract, fragmentation, lack of cohesion and integrity, and loss of the public's confidence. The present social contract is one-dimensional, overly simplistic, and failing to sustain the public's trust. To address these problems, a renewed social contract is necessary. Although this renewed contract should be based on foundations similar to the original, it must directly confront such contemporary challenges as resource allocation and conflicts of interest. Equally as important, to reinvigorate our social contract more physicians will need to come to grips with a basic truth: to sustain professionalism we need a strong, unified professional association.

Specialty board certification is a longstanding component of the US medical profession’s system of collective self-regulation. Although processes for board certification have changed over the years to match advancing medical practice and expanding public expectations of accountability, board certification has demonstrated to the public, the profession, colleagues, and the individual physician that certified specialists meet high specialtyspecific standards of education, expertise, and character.ThisViewpointdescribestheroleofboardcertification in collective professional self-regulation, current challenges and future directions.

If one presents oneself as a physician in the context of activism, one's remarks can be taken not just as the views of a thoughtful citizen but as those of someone who has expertise relevant to the situation.

Today, at the dawn of a new century, genuine medical professionalism is in peril. Increasing-ly, physicians encounter perverse financial incentives, fierce market competition, and the erosion of pa...

Importance Physicians’ views about health care costs are germane to pending policy reforms. Objective To assess physicians’ attitudes toward and perceived role in addressing health care costs. Design, Setting, and Participants A cross-sectional survey mailed in 2012 to 3897 US physicians randomly selected from the AMA Masterfile. Main Outcomes and Measures Enthusiasm for 17 cost-containment strategies and agreement with an 11-measure cost-consciousness scale. Results A total of 2556 physicians responded (response rate = 65%). Most believed that trial lawyers (60%), health insurance companies (59%), hospitals and health systems (56%), pharmaceutical and device manufacturers (56%), and patients (52%) have a “major responsibility” for reducing health care costs, whereas only 36% reported that practicing physicians have “major responsibility.” Most were “very enthusiastic” for “promoting continuity of care” (75%), “expanding access to quality and safety data” (51%), and “limiting access to expensive treatments with little net benefit” (51%) as a means of reducing health care costs. Few expressed enthusiasm for “eliminating fee-for-service payment models” (7%). Most physicians reported being “aware of the costs of the tests/treatments [they] recommend” (76%), agreed they should adhere to clinical guidelines that discourage the use of marginally beneficial care (79%), and agreed that they “should be solely devoted to individual patients’ best interests, even if that is expensive” (78%) and that “doctors need to take a more prominent role in limiting use of unnecessary tests” (89%). Most (85%) disagreed that they “should sometimes deny beneficial but costly services to certain patients because resources should go to other patients that need them more.” In multivariable logistic regression models testing associations with enthusiasm for key cost-containment strategies, having a salary plus bonus or salary-only compensation type was independently associated with enthusiasm for “eliminating fee for service” (salary plus bonus: odds ratio [OR], 3.3, 99% CI, 1.8-6.1; salary only: OR, 4.3, 99% CI, 2.2-8.5). In multivariable linear regression models, group or government practice setting (β = 0.87, 95% CI, 0.29 to 1.45, P = .004; and β = 0.99, 95% CI, 0.20 to 1.79, P = .01, respectively) and having a salary plus bonus compensation type (β = 0.82; 95% CI, 0.32 to 1.33; P = .002) were positively associated with cost-consciousness. Finding the “uncertainty involved in patient care disconcerting” was negatively associated with cost-consciousness (β = −1.95; 95% CI, −2.71 to −1.18; P Conclusion and Relevance In this survey about health care cost containment, US physicians reported having some responsibility to address health care costs in their practice and expressed general agreement about several quality initiatives to reduce cost but reported less enthusiasm for cost containment involving changes in payment models.

THE 1999 INSTITUTE OF MEDICINE REPORT TO ERR IS Human: Building a Safer Health System launched the modern patient safety movement by estimating a large number of yearly error-related deaths among hospitalized patients in the United States. But 12 years later, there are no reliable data on how many patients in the United States are injured or die each year because of errors in ambulatory settings. The number may be substantial; 52% of paid medical malpractice claims in 2009 were for events in the outpatient setting, and two-thirds of these claims involved major injury or death. More than 10 years ago, a group of experts convened by the Agency for Healthcare Research and Quality (AHRQ) reported that “medical error and injury are substantial in ambulatory care, [but] there has been little systematic research specifically aimed at patient safety questions in ambulatory care.” To jump-start a new research agenda, the conferees made 11 specific recommendations. Virtually none have been implemented.

The term “Electronic Health Records” (EHR) means something different to each of the stakeholders in health care, but it always seems to carry a degree of emotional baggage. Increasingly, EHRs are advertized as a nearly unmitigated good that will transform medical care, improve safety and efficiency, allow better patient engagement, and open the door to an era of cheap, effective, timely, and patient-centered care. Indeed, for some EHR proponents the benefits of adopting them are so obvious that adoption has become an end in itself. But for others — and especially for a number of skeptical practitioners and patients — EHR is a code word that portends the corporate transformation of health care delivery, the loss of patient privacy, the demand that patients bear more responsibility in health care, and the unreflective takeover of the health care system by people who do not understand medical care or how health care relationships unfold.

The authors argue that physician practices should routinely collect data on the race and ethnic group of their patients. They caution against the use of these data to infer information about health-related values or beliefs, and they discuss the benefit of using these data at the population level to detect disparities in care and to improve the quality of care.

To examine the association between physician race/ ethnicity, workplace discrimination, and physician job turnover.Cross-sectional, national survey conducted in 2006-2007 of practicing physicians (n = 529) randomly identified via the American Medical Association Masterfile and the National Medical Association membership roster. We assessed the relationships between career racial/ethnic discrimination at work and several career-related dependent variables, including 2 measures of physician turnover, career satisfaction, and contemplation of career change. We used standard frequency analyses, odds ratios and chi2 statistics, and multivariate logistic regression modeling to evaluate these associations.Physicians who self-identified as nonmajority were significantly more likely to have left at least 1 job because of workplace discrimination (black, 29%; Asian, 24%; other race, 21%; Hispanic/Latino, 20%; white, 9%). In multivariate models, having experienced racial/ethnic discrimination at work was associated with high job turnover (adjusted odds ratio, 2.7; 95% CI, 1.4-4.9). Among physicians who experienced workplace discrimination, only 45% of physicians were satisfied with their careers (vs 88% among those who had not experienced workplace discrimination, p value.01), and 40% were contemplating a career change (vs 10% among those who had not experienced workplace discrimination, p value.001).Workplace discrimination is associated with physician job turnover, career dissatisfaction, and contemplation of career change. These findings underscore the importance of monitoring for workplace discrimination and responding when opportunities for intervention and retention still exist.

Regulating clinical trials for testing new drugs is fraught with risk. Misregulation can slow development of innovative and useful new drugs, but in other ways misregulation can foster trials that are inefficient and unethical, driven by commercial rather than scientific ends, and that can harm patients. In this paper, we argue not for more but for better regulation, based on the goal of rapidly producing innovative and safe products that represent significant advances in medical care. Data on industry-funded, late-stage clinical trials demonstrate an urgent need for dramatic changes in how these trials are designed, conducted, and analyzed. On the one hand, current patent rules can dissuade development of innovative new products with smaller markets and press trial designers to create positive results too rapidly. But at the same time, numerous studies show that when the pharmaceutical industry sponsors clinical trials, the results are systematically biased in favor of the sponsor's product, often to the detriment of patients and the public. The reasons for this bias are both complex and unavoidable, and the ways in which clinical trial design, conduct, and reporting can be inappropriately influenced are so varied and nuanced, that efforts to manage this conflict of interest and prevent harms are inevitably unsuccessful. Instead, we conclude such conflict should be avoided and a strong firewall should exist between drug developers and the final stages of clinical testing in humans. All financial support for phase III clinical trials should pass through a public-private partnership organization — perhaps tied to a broader clinical effectiveness research enterprise — which would be charged with designing, funding, and monitoring late-stage human clinical trials of new pharmaceutical products.

An independent panel of experts, convened by the American Medical Association (AMA) Institute for Ethics, analyzed the roots of the racial divide within American medical organizations. In this, the first of a 2-part report, we describe 2 watershed moments that helped institutionalize the racial divide. The first occurred in the 1870s, when 2 medical societies from Washington, DC, sent rival delegations to the AMA's national meetings: an all-white delegation from a medical society that the US courts and Congress had formally censured for discriminating against black physicians; and an integrated delegation from a medical society led by physicians from Howard University. Through parliamentary maneuvers and variable enforcement of credentialing standards, the integrated delegation was twice excluded from the AMA's meetings, while the all-white society's delegations were admitted. AMA leaders then voted to devolve the power to select delegates to state societies, thereby accepting segregation in constituent societies and forcing African American physicians to create their own, separate organizations. A second watershed involved AMA-promoted educational reforms, including the 1910 Flexner report. Straightforwardly applied, the report's population-based criterion for determining the need for phySicians would have recommended increased training of African American physicians to serve the approximately 9 million African Americans in the segregated south. Instead, the report recommended closing all but 2 African American medical schools, helping to cement in place an African American educational system that was separate, unequal, and destined to be insufficient to the needs of African Americans nationwide.

Between 1910 and 1968, the National Medical Association (NMA) repeatedly clashed with the American Medical Association (AMA) over the latter organization's racial bars to membership and other health policy issues. The NMA, founded in 1895 as a nonexclusionary medical society to provide a voice for disenfranchised black physicians and patients, struggled in its early years, during which AMA leadership took scant notice of it. But skirmishes ensued over such actions as stigmatizing racial labels in the AMA's American Medical Directory, which, beginning in 1906, listed all U.S. physicians but designated African Americans with the notation col. The NMA also repeatedly asked the AMA to take action against overt racial bars on blacks' membership in its constituent state and county societies. During the civil rights era, African American physicians received no AMA support in seeking legal remedies to hospital segregation. And the NMA and AMA found themselves opposed on other policy issues, including Medicaid and Medicare. These differences eventually catalyzed a series of direct confrontations. The 1965 AMA meeting in New York City, for example, was protested by about 200 NMA-led picketers. The NMA's quest for racial equality in medicine was supported by some other medical organizations, such as the Medical Committee for Human Rights. In 1966, the AMA House voted to amend the AMA Constitution and Bylaws, giving its Judicial Council (now the Council on Ethical and Judicial Affairs) the authority to investigate allegations of discrimination. This paved the way for a subsequent era of increasing cooperation and understanding.

According to the former chief of training at the Navy's Survival, Evasion, Resistance and Escape (SERE) school, waterboarding is a "controlled drowning" that "occurs under the watch of a doctor, a psychologist, an interrogator and a trained strap-in/strap-out team." When waterboarding is used as part of mock interrogations during SERE training, "A team doctor watches the quantity of water that is ingested and for the physiological signs which show when the drowning effect goes from painful psychological experience to horrific, suffocating punishment, to the final death spiral." (1) Since waterboarding entails introducing liquid into the airway and risks letting water get sucked into the lungs, if it is to be demonstrated at all it makes sense for it to be done under close medical supervision. After all, a mock interrogatee could potentially die during waterboarding, even if only by accident. So why risk it? Well, a lot of military training is risky. Waterboarding, like other coercive interrogation techniques, is used during SERE training to prepare soldiers for what they might face at the hands of our enemies. The rationale is that some of our enemies might be unreservedly evil. They might believe our soldiers to be less than human. They might, like the Nazis, believe they are fighting "a decisive battle between two ideologies" and "an entirely new kind of war" in which "different standards" must be used. (2) Certainly, Al Qaeda has not adhered to the laws of war and has brutally tortured and murdered captives. In sum, when fighting evil totalitarians we need to train our soldiers based on the reality that they might be subjected to torture during interrogation. One question this raises is whether one can be trained to withstand torture. The training environment is artificial, of course. Soldiers are there voluntarily. A medical team is standing by, and the soldiers know their torturers won't actually kill them (at least not intentionally). But even so, experience shows that soldiers often withstand torture without releasing valuable information. During the Vietnam War, despite torture, only about 5 percent of the four hundred airmen captured signed anti-American propaganda statements, let alone divulged sensitive information. (3) Others have behaved similarly: In an examination of 625 instances of torture in France between 1500 and 1750, between 67 percent and 95 percent of victims never confessed, even "on the rack, under repeated drowning, crushing of joints, and the like." (4) When the victims of torture do "talk," they often--and perhaps intentionally--provide unreliable as well as true information. In fact, there is very little evidence that torture is effective as an interrogation technique, and some evidence that it can backfire dramatically. (5) But I digress. The real question at hand is how to hold to account the medical personnel needed to support waterboarding detainees. The method is so dangerous, according to the SERE trainer, that it can be carried out with any degree of safety only if a medical team is at hand. (6) This means, as Newsweek put it, that "presumably" medical teams have monitored the waterboarding of detainees by the CIA. (7) This would be consistent with written assertions from the administration that prisoners are "medically and operationally evaluated as suitable [for coercive interrogation] (considering all techniques to be used in combination)." (8) It would also fit with the leaked assessment of the International Committee of the Red Cross, referring to conditions at Guantanamo, that U.S. physician involvement in coercive interrogations there constituted "a flagrant violation of medical ethics." (9) Beyond ethics, participation in water-boarding could also put these physicians in significant legal jeopardy as parties to a war crime. But this is where the story gets strange. Torture has long been illegal under U.S. law. Since 1984, the legal definition of torture in the United States has been "any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person for such purposes as obtaining from him or a third person information or a confession. …

As the American system of health care delivery strains under the weight of erratic coverage, inefficiency, and uncertain quality, proposals for how it should be reformed have proliferated. (1) Some proposals focus primarily on improving quality, others on restraining costs; all, directly or indirectly, address access to health care. (2) We present a consensus framework for evaluating how well a proposal addresses the issue. While access is affected by a number of factors (geography, distribution of providers, and so on), for this essay we focus primarily on ethical issues in access to health care coverage. The framework emerges from the work of the multi-stakeholder Ethical Force Program, which uses a standardized process derived from well-accepted methods for generating consensus on clinical practice guidelines and measuring quality in health care. (3) The program is a collaborative initiative led by the Institute for Ethics at the American Medical Association. It was established in 1997 "to improve health care by advancing ethical behavior among all participants." (4) It is motivated by the beliefs that ethical standards are fundamental to health care systems that are effective and trusted, that all stakeholders in health care should be accountable for their ethics, and that stakeholders must work together to ensure that shared ethical standards are widely promoted, understood, and followed. (5) The program functions as a national quality improvement organization for health care ethics. As such, it produces an array of reports and tools that all stakeholders can use to assess and improve the ethical environment of health care. The method by which it produces consensus statements has been described in detail elsewhere. (6) In brief, it runs as follows. An oversight body provides guidance on all programmatic activities. (For a list of the members, see the accompanying box.) The oversight body comprises a diverse group of leaders from all aspects of health care delivery, including clinicians, patients, provider organizations, purchasers, and others. The AMA holds two seats on the oversight body; the Agency for Health Care Research and Quality, the American Hospital Association, The Joint Commission, and the National Committee for Quality Assurance also hold permanent seats. The remaining seats are filled to three-year terms by vote of the oversight body, which seeks to ensure diverse perspectives and involvement. To determine consensus on recommendations, the oversight body votes on whether members support each recommendation using a one to ten scale. A statement is rejected if it fails to achieve an average score of greater than seven or if any member gives it a vote of less than three. We used this consensus process to come to agreement on four core ethical obligations for health system reforms that aim to improve access to care. We present these obligations with a number of more specific consensus recommendations that follow from taking the four ethical obligations seriously. Access to Health Care as an Ethical Issue As the number of Americans without health care coverage continues to increase, access to care is a major political, economic, and policy problem. Unequal access to health care is also an ethical issue. Most Americans understand this: 72 percent think our society should ensure universal access to health care, and 60 percent consider it to be a moral rather than a strictly political or economic issue. (7) We hold that three core American values are at stake: equality of opportunity, justice, and compassion. Equality of opportunity is essential for each of us to fulfill the American promise of life, liberty, and the pursuit of happiness, and personal health is an essential ingredient to ensure opportunity. (8) Equality of opportunity is compromised whenever identifiable subpopulations of American society are disproportionately affected by limited access to care. For instance, it belies the American ideal that all are created equal when disparities in access to care lead to consistently poorer health outcomes for specific racial and ethnic groups. …

Objectives Potential bioterrorism challenges policy makers to balance competing public health priorities. Earlier surveys showed low physician bioterrorism preparedness but did not assess physicians' general public health preparedness, compare the preparedness of emergency and primary care physicians, or assess temporal trends. Methods This was a national, cross-sectional, random-sample survey conducted in 2003. Results Overall, 744 of 1,200 eligible physicians responded (response rate, 62%). Of these, 58% of emergency physician respondents and 48% of primary care physician respondents reported having learned a lot about responding to bioterror since September 11, 2001 (p < 0.01). However, only 43% of emergency physicians and 21% of primary care physicians agreed they are generally “well prepared to play a role in responding to a bioterror attack” (p < 0.001). Beliefs about balancing public health priorities were similar among emergency and primary care respondents. Seventy-eight percent of respondents believed that local health care systems need to be prepared for bioterrorism, and 92% believed that local health care systems need to be prepared for natural epidemics. By contrast, only 23% and 46% of respondents reported that their local health care systems are well prepared for bioterrorism and natural epidemics, respectively. Meanwhile, 77% agreed that “influenza is a greater threat to public health than bioterrorism,” and 21% reported that bioterrorism preparedness efforts are diverting resources from more important public health problems. Conclusions In 2003, most emergency and primary care physicians reported that they and their local health care systems were not yet well prepared to respond to a bioterror attack, and many believed that more resources should go toward preparing for natural epidemics. These findings highlight the importance of expanding bioterrorism preparedness efforts to improve the public health system more broadly.

Objective To assess US physicians’ attitudes towards using shared decision-making (SDM) to achieve cost containment. Design Cross-sectional mailed survey. Setting US medical practice. Participants 3897 physicians were randomly selected from the AMA Physician Masterfile. Of these, 2556 completed the survey. Main outcome measures Level of enthusiasm for “Promoting better conversations with patients as a means of lowering healthcare costs”; degree of agreement with “Decision support tools that show costs would be helpful in my practice” and agreement with “should promoting SDM be legislated to control overall healthcare costs”. Results Of 2556 respondents (response rate (RR) 65%), two-thirds (67%) were ‘very enthusiastic’ about promoting SDM as a means of reducing healthcare costs. Most (70%) agreed decision support tools that show costs would be helpful in their practice, but only 24% agreed with legislating SDM to control costs. Compared with physicians with billing-only compensation, respondents with salary compensation were more likely to strongly agree that decision support tools showing costs would be helpful (OR 1.4; 95% CI 1.1 to 1.7). Primary care physicians (vs surgeons, OR 1.4; 95% CI 1.0 to 1.6) expressed more enthusiasm for SDM being legislated as a means to address healthcare costs. Conclusions Most US physicians express enthusiasm about using SDM to help contain costs. They believe decision support tools that show costs would be useful. Few agree that SDM should be legislated as a means to control healthcare costs.

ContextHealth plan utilization review rules are intended to enforce insurance contracts and can alter and constrain the services that physicians provide to their patients. Physicians can manipulate these rules, but how often they do so is unknown.ObjectiveTo determine the frequency with which physicians manipulate reimbursement rules to obtain coverage for services they perceive as necessary, and the physician attitudes and personal and practice characteristics associated with these manipulations.Design, Setting, and ParticipantsA random national sample of 1124 practicing physicians was surveyed by mail in 1998; the response rate was 64% (n = 720).Main Outcome MeasureUse of 3 different tactics "sometimes" or more often in the last year: (1) exaggerating the severity of patients' conditions; (2) changing patients' billing diagnoses; and/or (3) reporting signs or symptoms that patients did not have to help the patients secure coverage for needed care.ResultsThirty-nine percent of physicians reported using at least 1 tactic "sometimes" or more often in the last year. In multivariate models comparing these physicians with physicians who "never" or "rarely" used any of these tactics, physicians using these tactics were more likely to (1) believe that "gaming the system" is necessary to provide high-quality care today (odds ratio [OR], 3.67; 95% confidence interval [CI], 2.54-5.29); (2) have received requests from patients to deceive insurers (OR, 2.44; 95% CI, 1.72-3.45); (3) feel pressed for time during patient visits (OR, 1.69; 95% CI, 1.21-2.37); and (4) have more than 25% of their patients covered by Medicaid (OR, 1.60; 95% CI, 1.08-2.38). Notably, greater worry about prosecution for fraud did not affect physicians' use of these tactics (P = .34). Of those reporting using these tactics, 54% reported doing so more often now than 5 years ago.ConclusionsA sizable minority of physicians report manipulating reimbursement rules so patients can receive care that physicians perceive is necessary. Unless novel strategies are developed to address this, greater utilization restrictions in the health care system are likely to increase physicians' use of such manipulative "covert advocacy" tactics.

FINANCIAL INCENTIVES that influence physician decision making are unavoidable. 1 Under the traditional fee-for-service system of physician payment, services that provide benefit to the patient also hold the promise of additional revenue for the physician. In conjunction with health insurance, this payment system strongly promotes increased use of resources, 2 and many health economists believe that fee-for-service payment of physicians has been a major contributor to the rapid growth in health care costs in the United States. 3 With annual rates of growth in health care expenditures continuing to outstrip the rate of growth of the economy, business and government have turned to alterations in physicians' financial incentives to assist in limiting health care expenditures. 4 In particular, managed care plans using capitated payments to physicians are becoming more common. 5 Under capitation, in its simplest form, physicians, either individually or in a group, receive a fixed payment

TEAM-BASED HEALTH CARE MAY HELP THE UNITED STATES achieve improved health and improved health care at asustainablecost. It iscentraltomanyreformsofhealth care delivery, both actual and proposed. Team-based carecanoccur inmanysettings (eg,home,office,hospital); focus on different problems (eg, specific diseases); and include teammemberswithavarietyofbackgrounds.Healthcareteams can be large or small, centralized or dispersed, virtual or faceto-face, and their tasks can be focused and brief or broad and lengthy.Thisextremeheterogeneity in tasks, foci, andsettings presentsachallengetodefiningoptimalteam-basedhealthcare. Recently,we ledaworkinggroup—ateamcomprisingapatientadvocate,physician, registerednurse,physicianassistant, social worker, and pharmacist—convened by the Institute of Medicine(IOM)toexplorethefoundationsofteam-basedhealth care. The background work included structured discussions with high-functioning teams from a variety of settings, which revealedthatsuchteamsareguidedbyasetofsharedprinciples and values that can be measured, compared, learned, and replicated (BOX). These principles and values are seemingly straightforward. But considering the realities of implementation and spread of team-basedcarealignedwiththeseprinciplesandvaluesraised difficult issues—3 of which deserve focused attention.

Racial and ethnic minorities often receive lower-quality health care than white patients, even when socioeconomic status, education, access, and other factors are used as controls. To address these pervasive disparities, health care professionals should learn more about them and the roles they can play in eliminating them, but few curricula are focused on understanding and addressing racial and ethnic health disparities, and well-accepted guidelines on what and how to teach in this complex area are lacking. The Society of General Internal Medicine Health Disparities Task Force used a review and consensus process to develop specific recommendations and guidelines for curricula focusing on health disparities. Learning objectives, content, methods for teaching, and useful resources are provided. Although the guidelines were developed primarily for teaching medical students, residents, and practitioners in primary care, the Task Force's general recommendations can apply to learners in any specialty. The Task Force recommends that a curricula address 3 areas of racial and ethnic health disparities and focus on the following specific learning objectives:1) examining and understanding attitudes, such as mistrust, subconscious bias, and stereotyping, which practitioners and patients may bring to clinical encounters; 2) gaining knowledge of the existence and magnitude of health disparities, including the multifactorial causes of health disparities and the many solutions required to diminish or eliminate them; and 3) acquiring the skills to effectively communicate and negotiate across cultures, languages, and literacy levels, including the use of key tools to improve communication. The broad goal of a curriculum on disparities should be for learners to develop a commitment to eliminating inequities in health care quality by understanding and assuming their professional role in addressing this pressing health care crisis.

David Wendler and colleagues [ 1] have provided important data to help understand disparities in access to medical research among minorities. It is unfortunate, however, that they draw an unwarranted conclusion from a set of extremely heterogeneous studies. Worse still, by suggesting that the substantial body of research demonstrating how common it is for African Americans to mistrust the health-care system [ 2–4] is wrong, the authors imply that we do not need to come to terms with why this mistrust exists and how it should be addressed by the medical profession. Wendler et al. note the extreme heterogeneity of the trials included in their study, but they ignore how much this affects the reliability of the meta-analytic techniques they employ. First, the vast majority of the “more than 70,000” patients studied was only involved in survey research—where large differences in response rates between races are not generally seen. Looking only at the clinical trials, the numbers are much smaller and the data become much more difficult to summarize. Among the seven surgical intervention trials studied, two have statistically significant differences between minority enrollment and white enrollment. In one, whites had about 2.7 times greater odds of enrollment than minorities, while in the other, minorities had about 1.6 times greater odds of enrollment than whites. In the ten clinical trials studied, three had statistically different enrollment rates; they, too, had greatly diverging results. For the most part, though, the clinical trials that Wendler et al. examined enrolled so few minority patients (in half of the studies, fewer than 50 minority patients were even asked to enroll), and they are so vastly different in design and objectives that very little information can be reliably gleaned from pooling their results. In fact, one of the largest trials included—the Minority-Based Community Clinical Oncology Program (MBCCOP) cancer trial, which included more than 400 African Americans—was specifically designed to appeal to minority patients, making any assumptions about its generalizability to all medical research extremely suspect. It is well known that meta-analysis is subject to this sort of problem; statistical tricks simply can't account for fundamental differences in studies. Despite these scientific weaknesses, Wendler et al. are right to conclude that it is inappropriate to focus on changing African Americans' attitudes of mistrust, but not because those attitudes don't exist. Many minorities don't feel welcome and respected within the health-care system. Those who do come in have already crossed a threshold of trust, at least with their individual doctor. Those who don't come in, of course, will never have the opportunity to be asked to enroll in a clinical trial. Instead, the reason it would be inappropriate to focus on changing patient attitudes is because these attitudes of mistrust are based on a history of untrustworthy behavior by the health professions, which must be acknowledged and rectified. In other words, the medical profession should not focus on making minorities be more trusting; we should focus on ensuring that we are becoming trustworthy.

To the Editor. —We were surprised that Dr Brook and colleagues 1 believe that "[q]uality-of-care reporting systems need to rely primarily on clinically valid process (vs outcomes) measures." Granted there remain technical and conceptual problems with outcomes measures: rare outcomes, like mortality, are insensitive measures of quality; many quality-of-life measures must rely on risk adjustment to form appropriate comparisons between various organizations and providers; and disease-specific outcomes measures are still in development. However, process measures are imperfect as well. Three facts argue for the use of outcomes measures at least as often as process measures for quality control. First, while outcomes are sometimes not sensitive as a measure of quality (the absence of a bad outcome does not necessarily imply good quality), the corollary is that process measures are not specific measures of quality (the mere presence of a process may not imply good quality). For example, a high level